The purpose of this research is to examine the performance of hospitals belonging to different kinds of multi-unit systems and to explain differences in performance as a function of the environment, strategy, and structure associated with the different systems. Specific aims include: 1) to document and explain differences in cost/productivity, access, and quality of care within and between system hospitals (both investor-owned and voluntary) and selected free standing non-profit hospitals; 2) to document and explain differences in strategy/structure/performance relationships within and between investor-owned and voluntary systems in regard to cost/productivity, profitability/financial status, access and quality of care; and 3) to examine the relationship between multi-unit systems' strategies, the effect of these strategies on structure, and, in turn, the effect of strategy and structure on performance. Most of the above relationships are examined over the period 1978-1985 and, thus, permit examination of the effects of the introduction of Medicare Prospective Payment on hospital strategy, structure, and performance. The above objectives are accomplished by examining the relationships among environment, strategy, structure, and performance in eight multi-unit hospital systems involving 541 hospitals; three investor-owned (American Medical International, Hospital Corporation of America, and National Medical Enterprises) and five voluntary multi-unit systems (Evangelical Health Systems, Health Central, InterMountain, Sisters of Mercy Health Care Corporation, and Southwest Community Health Services). These systems and their associated hospitals are selected to represent key variables of interest including ownership status, religious affiliation versus non-religious affiliation, georgraphically concentrated versus geographically dispersed systems, urban versus rural, and differences in centralization of decision-making. In addition, for selected performance measures (access, cost, and outcome measures of quality) the multi-unit system hospitals are compared with approximately 500 free-standing hospitals operating in the same geographic market areas. Among the performance measures examined are: costper adjusted in-patient admission, cost per adjusted in-patient day, operating margin, debt/equity ratios, return on assets, scope of geriatric care anc ambulatory care services offered to the community, and diagnostic-specific standardized mortality ratios and hospital readmission rates.